12 Composite Resins

J. C. L. Neo ! A. U. J. Yap

T
he first of the resin restorative
materials was launched in the
early 1950s but, as it was
unfilled it was not successful and was
rapidly abandoned. The concept of
adhesion between resin and enamel
was first investigated by Buonocore
about the same time but it was not
until the concept of adding fillers to
the resin matrix was evolved in the
1960s that there was any sign of suc-
cess. From that time on there has
been considerable research undertak-
en until at this time the so-called
composite resins are the material of
choice in many circumstances. It is
possible to achieve a very high level of
aesthetic replacement of tooth struc-
ture and, in the presence of an enam-
el margin around the full circumfer-
ence of the cavity, a restoration will
show minimal signs of microleakage.
The longevity of the individual
restoration is highly dependent on the
care and skill of the operator who
must work within the limitations of
the material.
200 Preservation and Restoration of Tooth Structure

Introduction are based on the incorporation of prereacted glass-

ionomer technology. The basic glass filler is react-
ed with acidic polymers in water prior to inclusion
into a silica filled resin. Manufacturer’s claims
The continuum of direct aesthetic
include fluoride release and recharge, biocompati-
restorative materials
bility, clinical stability, excellent aesthetics and a

T he clinical use of direct aesthetic restorative

materials has increased substantially in recent
years fuelled by increased aesthetic demands by
smooth surface finish. Independent studies on
giomers are currently limited and do not fully sub-
stantiate these claims. The few that have been
patients and the decline in the popularity of amal- published suggest that they have a surface finish
gam as a restorative material. The latter may be that compares well with compomers and compos-
attributed to the fear of the potential toxicity and ite resins.3 However, the long term fluoride release
the possible environmental effects of mercury. is questionable4 and the ion exchange adhesion is
Glass-ionomers and composite resins form the not available so they belong with composite resins
two extreme ends of the continuum of direct and not with glass-ionomers.
restorative materials (Figure 12.1). Glass-ionomers
consist of basic glasses and acidic co-polymers
and set by an acid/base reaction. Composite resins Composites, compomers and giomers
are basically ceramic filled polymers which set by Composites resins may be defined as three-
resin polymerisation. The advantages of glass- dimensional combinations of at least two chemi-
ionomers include chemical bonding to tooth cally different materials with a distinct interface.5
structure through an ion exchange mechanism, They were introduced to the dental profession in
fluoride release and a high level of bioactivity. the early 1960s. Micromechanical bonding of
The qualities of composite resin include excellent unfilled resins to enamel via acid etching was
aesthetics and acceptable physical properties but already established in the 1950s but the unfilled
placement techniques are quite demanding. resin materials then in use suffered a high poly-
Attempts to combine the properties of the two merisation shrinkage, a high coefficient of ther-
materials have lead to the development of a num- mal expansion and poor physicomechanical char-
ber of hybrid materials. These include resin-mod- acteristics so that they were not satisfactory as a
ified glass-ionomers, compomers and, more restorative material. They were originally chemi-
recently, giomers. cally activated and light activated versions were
Resin-modified glass-ionomers are hybrid mate- subsequently developed in the 1970s. Combined
rials that retain an acid/base setting reaction as a materials using both chemical and light activation
significant part of their overall curing process, as
well as the bioactivity and ion exchange adhesion
of the glass-ionomers.1 In contrast, compomers
are materials that contain either or both of the
essential components of glass-ionomers but at
levels insufficient to promote the acid/base set-
ting reaction or the ion exchange adhesion.2 The
filler is an ionomer glass and a variable amount of
dehydrated polyacrylic acid is incorporated into a
resin matrix. The acid is activated when water is
absorbed into the restoration and subsequently
reacts with the glass. However, the delayed reac-
tion does not allow for development of an ion
exchange adhesion nor a prolonged fluoride
release. Fig. 12.1. Continuum of direct tooth coloured restorative
Giomers, the latest category of hybrid materials, materials.
 Composite Resins 201

systems are now available for core build-ups and Composition, Setting
luting purposes.
The current versions of composite resins, com- and Classification
pomers and giomers are all packaged as a single
paste system, are light polymerised and require
bonding systems to promote adhesion to tooth Composition
structure. They are made up of an organic phase
in the form of a resin matrix, and this contains a
dispersed phase in the form of inorganic filler par-
T he major components of a composite resin are
as follows:
• Organic phase
ticles. At the interface between the two there is a ! most composite resins contain the aro-
coupling agent. There are also minor additives matic oligomer Bis-GMA dimethacrylate
such as polymerisation initiators, activators, col- ! some contain urethane dimethacrylate.
oring pigments and stabilisers. ! Bis-GMA is highly viscous and shows
The base monomers include Bis-GMA (Bisphe- polymerisation shrinkage and water
nol A glycidyl methacrylate) or UDMA (urethane sorption. A diluent like TEGDMA is gen-
dimethacrylate) as well as diluents like TEGDMA erally added to reduce the viscosity.
(Triethyleneglycol dimethacrylate). The organic • Inorganic phase
phase of a compomer also contains resins with ! filler particles are usually glasses con-
functional acid groups, such as TCB, which is a taining aluminium, barium, strontium,
reaction product between butanetetracarboxylic zinc, zirconium or quartz with size rang-
acid and hydroxyethyl methacrylate (HEMA) ing from 0.1-10 µm
and/or CDMA which is an oligomer derived from ! alternate fillers can be silica with particle
citric acid. At present the commercially available sizes from 0.04-0.2 µm
giomers are UDMA-based. • Interfacial phase – coupling agent
Many of these materials contain amorphous sil- ! to bind the filler to the matrix
ica with an average particle size of 0.04 µm as the ! to act as stress absorber allowing stresses
filler and these may be included as individual par- in the resin to be transferred between
ticles or as pre-polymerised fillers. To achieve filler particles via the weaker matrix
radiopacity, silicate particles based on aluminium, • Miscellaneous phases
strontium or barium oxides are also incorporated. ! accelerators and initiators
Compomers and giomers also contain fluorosili- Filler loading is expressed as volume % or
cate glass or ytterbium trifluoride fillers to pro- weight % and contributes to the physical and
vide some level of fluoride release. mechanical properties of strength, stiffness,
Silane coupling agents are commonly employed dimensional change, setting contraction, radio-
to ensure bonding between filler particles and the pacity and improved handling. Both the size and
resin matrix. Silane molecules have silanol and the size distribution of the filler particles play a
methacrylate groups at their extreme ends and part in the characteristics of each material. The
these attach to the silica based fillers and the smaller the filler particle size, the better the pol-
methacrylate groups in the resin matrix respec- ishability. The ideal combination of filler size
tively.6 involves a combination of two or more sizes of
filler particles to allow for more efficient packing.
Chemically cured composite resins contain ben-
zoyl peroxide as the initiator combined with a ter-
tiary aromatic amine accelerator to produce free
radicals for polymerisation.
Light activated composite resins contain cam-
phorquinone and a tertiary amine as the photoini-
tiators, pigments and UV absorbers. Pigments in
202 Preservation and Restoration of Tooth Structure

the form of oxides are added to provide a variety TABLE 12.2

of shades. Ultraviolet absorbers stabilise potential
colour changes. Category Particle size Category Particle size
(µ) (µ)

Megafill 0.5 Minifill 0.1-1

Setting reactions
Macrofill 10-100 Microfill 0.01-0.1
The setting reaction is a free radical addition poly-
merisation. The production of free radicals propa- Midfill 1-10 Nanofill 0.005-0.01
gates the reaction leading to a highly cross-linked After Bayne et.al.
polymer. For the chemically cured resins, the ini-
tiator, benzoyl peroxide, is activated by the terti- In recent years, two further categories of mate-
ary aromatic amine. For photocured resins, visible rials were introduced, this time related to varia-
light with an approximate wavelength of 470 nm tions in their filler loading.
activates the photoinitiator. The co-initiator inter-
acts with the activated photoinitiator producing Flowables
free radicals for the start of the polymerisation Launched in late 1996, in response to dentists’
process. For dual curing resins, the process of requests, the flowables were developed to improve
chemical and light curing are both incorporated handling characteristics. The filler particle sizes
in the system. range from 0.04-1 µm and there is a reduction in
filler content down to 44-54%, thus reducing the
viscosity of the material allowing for better flow to
Classification systems poorly accessible areas.
The system of classification in recent years has They have a higher resin content so it is under-
been based on the particle size and size distribu- standable that mechanical properties are less than
tion and the percentage filler loading of the resin. the traditional composites. With a lower modulus
The classification introduced by Lutz and Phillips of elasticity and better wettability, they are expect-
19837 describes the following groups: ed to serve as an intermediate layer between the
adhesive layer and the overlying resin to reduce
contraction stress and consequently improve the
TABLE 12.1
seal of the restoration.9 Initial indications included
Category Particle size Filler loading Particles a long list but increasing evidence has limited
(µ) (by weight) their applications. There may be some benefit
Traditional/ 1-15 70-80% quartz from improved flow as long as they are not associ-
Macrofillers ated with high stress.10 Examples include cervical
Microfine/ 0.04-0.2 50-60% amorphous restorations, or as a liner at the gingival margin in
microfillers silica the proximal box in a posterior restoration.
Fine particles 0.4-3 70-90% ground However, the data to support its use to decrease
glass/quartz polymerisation stress or microleakage is not con-
Hybrids/ 77-84% macrofillers
clusive.11,12
blends plus micro-
fillers Packables
After Lutz and Phillips Shortly after the introduction of the flowables, the
packable or condensable composites were market-
Subsequently Bayne8 offered a further classifi- ed as a posterior restorative material with the han-
cation based also upon particle size and divided dling properties of dental amalgam. The filler
into six categories. loading is within the range of 48-65 % by volume,
and the filler particle sizes vary from 0.7–20 µm.
The fillers include fused particle agglomerate,
 Composite Resins 203

fibrous filler or improved filler particle packing.13 Depth of cure

These are claimed to impart better physical and Although depth of cure is not a problem with
mechanical properties so they can be used in load chemically activated materials, it presents a prob-
bearing situations. Clinically, the material is less lem for those that are light activated. The pres-
sticky and more viscous making it easier to estab- ence of a hard surface on a newly placed restora-
lish proximal contact. Other reported advantages tion does not necessarily mean that there has
include placement in bulk and reduced polymeri- been adequate polymerisation throughout the
sation shrinkage. However, the data to support entire restoration.19 Inadequate curing of the
claims that they are better than the traditional lower layers of a restoration may result in gap for-
hybrid materials have not been substantiated. mation, marginal leakage, recurrent caries, pulpal
sensitivity and ultimate restoration failure.20
The depth of cure is affected by many factors
Properties including
• filler type and composition
• resin chemistry
• shade and translucency
Setting time • activator-initiator concentration

T he setting time of a composite resin depends

on the method of activation. Two-paste chemi-
cally activated systems have a setting time rang-
• intensity, spectral distribution and duration
of light curing21
Composite resin restorations should be built in
ing from 3-6 minutes from the start of mixing. The increments no greater than 2 mm thick in order to
setting time of a one-paste light activated system obtain maximum, uniform polymerisation despite
is highly dependent on the light source and the some manufacturers’ claims.22 The exit window of
exposure time. Light curing time ranges from 3-40 the light curing tip must be constantly held with-
seconds depending on a variety of factors includ- in 3-4 mm of the surface of the restoration to
ing type and intensity of the light source, the obtain optimum effect.
shade and the thickness of the material. A mini-
mum light intensity of 400 mW/cm2 has been rec-
ommended for routine curing of all dental com-
NOTE "
posites.14 The use of a higher intensity light will • Composites must be cured in increments no
greater than 2 mm
reduce the curing time and increase polymerisa-
• Light curing tips must be held within 4 mm of the
tion but it may also increase shrinkage and there-
surface of the restoration at all times
fore microleakage.15
Light activated materials continue to poly-
merise and shrink after removal of the curing Thermal properties
light16 because for both chemical and light activat- Ideally the thermal expansion of a restorative
ed materials, conversion of monomer to polymer material should be similar to tooth structure in
is never quite complete. Approximately 25-40% of order to maintain the integrity of the interface
double bonds remain unreacted17 and there is a between the restoration and the cavity wall. The
possibility that these unbonded monomers may coefficient of thermal expansion of a composite
be cytotoxic to the pulp.18 resin is approximately three times greater than
tooth structure and this varies with the percent-
NOTE " age filler content. Composite resins with lower
filler volume, such as a microfil, will therefore
• Composite resins can never be over cured
have a higher thermal expansion compared to a
• Curing lights must be checked regularly to ensure
the intensity is beyond 400mW/cm2 more highly filled material. Despite this, it seems
that few clinical problems arise from this proper-
ty. It is possible that this may be attributed to the
204 Preservation and Restoration of Tooth Structure

transient nature of thermal stressors as well as Color stability may, to a degree, be shade depend-
the low thermal conductivity of composite resins. ent with lighter shades undergoing a greater
Glass-ionomer bases are often incorporated under colour shift.32 It is also important to note that both
composite restorations to reduce the bulk of com- composite resins and compomers undergo some
posite required and therefore, indirectly, the poly- degree of color change during light polymerisa-
merisation shrinkage, rather than for thermal tion33 so shade selection can be compromised. It is
insulation. suggested that, at the time of shade selection,
accuracy of choice can be enhanced by polymeri-
Water sorption and solubility sation of a small piece of the relevant material on
Composite resins have been shown to absorb to wet tooth structure adjacent to the cavity.
water and expand but the sorption process takes
time and may not be sufficient to compensate for
polymerisation shrinkage.
NOTE "
Where aesthetic demands are high, confirm shade
selection by polymerising some of the selected resin
BE AWARE ! on to the tooth involved before it has become
dehydrated.
• Composite resins take up water
• Compomers take up more water than composites
• Giomers take up the most water, leading to Radiopacity
greater marginal gap reduction23
Radiopacity is an important property as it enables
the clinician to detect recurrent caries and mar-
Water sorption is largely dependent on the resin ginal defects. It is particularly important when
matrix23 and has been shown to reduce physico- the cervical margin of a composite resin restora-
mechanical properties of composite resins includ- tion is in dentin. Radiopacity is achieved by the
ing hardness and wear resistance.24 Curing a incorporation of silicate particles based on the
restoration with an activator light that does not oxides of heavy metals such as barium (Ba), zirco-
have the full intensity nium (Zr) and strontium (Sr). Ytterbium trifluo-
required for proper poly-
BE AWARE ! ride is also used in some materials.
merisation will compro- Composite resins
mise water sorption and absorb water over
solubility. The solubili-
25 time causing marginal Mechanical properties
staining.
ty is also dependent on The mechanical properties of composite resins
the resin composition. 26
vary with filler volume percent. This means that
increased filler loading will increase hardness,
Color stability stiffness, strength and fracture toughness. As
The color changes associated with composite microfill and flowable composites have lower
resins can be either extrinsic or intrinsic in origin. filler loading than minifill and midifill compos-
Extrinsic color changes result from the incorpora- ites, their mechanical properties are expected to
tion of staining agents such as coffee, tea or black be lower. Therefore the first two should not be
cola drinks into the surface of a restoration. This used in stress-bearing areas such as the occlusal
may be related, at least in part, to the surface fin- surfaces of posterior teeth.
ish and porosity of the materials. The use of cer- However, the lower stiffness or modulus of elas-
tain mouthrinses and bleaching agents may also ticity is an advantage in the restoration of non-
cause discoloration of some composites and com- carious cervical lesions where it is desirable that
pomers.27,28 The intrinsic color stability of light the restoration is able to flex in response to cervi-
activated composites is superior to chemically cal deformation during function or parafunction.34
activated ones29 and that of composites is superior The mechanical properties of composite resins
to compomers which are more hydrophilic.30,31 are generally superior to those of compomers and
 Composite Resins 205

giomers especially when exposed to an acid envi- The wear resistance of restorative materials is
ronment. best assessed clinically as it is difficult to simulate
the complex loadings, movement and chemical
environment of the mouth. In vitro wear testing
NOTE " remains popular due to the cost and time involved
• Composite resins with higher filler volumes in running clinical trials, problems associated
generally have better mechanical properties with patient recruitment/fallout and large vari-
• In carious or non-carious cervical lesions, ance in clinical data arising from widely differing
composite resins with lower filler volumes are cavity shapes, locations and stresses. Despite the
preferred
large number of complex wear devices/tests avail-
able, the correlation between in vitro and in vivo
Wear findings is still poor.35 The wear resistance of par-
Wear occurs whenever two surfaces move in con- ticular composite resins may also vary between
tact with each other. Clinical wear mechanisms OCA and CFA wear patterns. Due to differences in
can be divided into occlusal contact area (OCA) experimental designs and methods of measure-
and contact free area (CFA) wear.35 OCA wear ment, the best way to draw conclusions from var-
results from the combined effect of direct tooth ious studies is to consider the ranking of the eval-
contact during function and indirect tooth contact uated materials within each study. Although the
via trapped particles during the closed phase of wear resistance of microfill composites is general-
mastication. CFA wear or slurry wear occurs dur- ly better than minifill and midifill composites,37
ing the open phase of mastication and toothbrush- they appear to fail catastrophically after pro-
ing. In restorations of conservative size, the wear longed fatigue38 (Figure 12.2). The wear mechanism
of many current composite resins is similar to that of different composites is dependent on material
of amalgam being in the range of 10-20 µm a year.36 microstructure and a wide variety of conditions
However, it has been shown that the OCA wear of including contact stress,
composites can exceed that of CFA wear by three duration and chemical
BE AWARE !
to five times. Hence, composite resin wear is still environment. In general, Composite resin wear
a problem for large restorations as substantial the wear resistance of is a problem in large
wear may lead to changes in functional occlusion composite resins is supe- stress-bearing
restorations.
and deeper intercuspation (Chapter 18). rior to compomers and
giomers.39

Polymerisation shrinkage
Despite advances made in resin formulation,
polymerisation shrinkage continues to be a prob-
lem with all resin-based restorative materials.
Shrinkage will vary between 1-5% volume40 and
can be divided into pre-gel and post-gel phases.41
During the pre-gel phase, the composite resin is
able to flow and stress within the structure will be
relieved. After gelation, that is, in the post-gel
phase, flow ceases and cannot compensate for
shrinkage stresses. This will result in significant
stress in the surrounding tooth structure as well
as the composite resin to tooth bond.42 This can
lead to postoperative sensitivity, tooth fracture,
Fig. 12.2. Presence of microscopic cracks that may contribute
to catastrophic failure of microfill composites after extensive microleakage (Figure 12.3) and secondary caries.
OCA wear. There are a number of methods available to
206 Preservation and Restoration of Tooth Structure

reduce the effects of polymerisation shrinkage

including
BE AWARE !
• incremental placement of composite resin in • Polymerisation shrinkage continues to be a
to the cavity problem with composite resins
• placement of a glass-ionomer base to reduce • Take care to reduce this clinically during
the volume of composite required placement
• glass-ionomer liner to act as a shock absorber • Shrinkage is generally towards the light source
• the development of stronger bonding agents
• the use of ‘soft-start’ ‘pulse cure’ or other
modified methods of light curing Bonding to enamel
There are a number of light curing regimens Bonding of composite resins, compomers and
available designed to allow for the composite giomers to both enamel and dentine is primarily
resin to flow during setting by means of con- micromechanical in nature.43 The bond to enamel
trolled polymerisation. It has been shown that is entirely micromechanical. The enamel margin
shrinkage stresses can be reduced through some should be etched with 37% phosphoric acid for 15
of these techniques but the problem remains. In seconds then washed thoroughly to remove all
general, the smaller the filler content, the greater etchant and debris. This results in selective disso-
the polymerisation shrinkage. Hence, microfill lution of the outer surface of the enamel rods
and flowable composites have greater shrinkage leading to the development of microporosities of
than their more highly filled counterparts. Comp- up to 30 µm in depth. A low viscosity resin is then
omers, by nature of their setting chemistry, applied with the expectation that it will penetrate
absorb water and expand. Although hygroscopic into the microporosities leading to the develop-
expansion may compensate for polymerisation ment of resin-tags. Although resin bonding to
shrinkage, the process takes time to occur and enamel is reliable and strong, there are a number
will allow other problems to develop such as mar- of factors of importance that can reduce its effi-
ginal staining of restorations. The ultimate solu- ciency –
tion to the problem lies in the development of • poor clinical techniques
nonshrinking polymers. • contamination of the enamel surface after
etching
• development of microcracks in the enamel
during cavity preparation
• presence of unsupported or fractured enam-
el margins

Bonding to dentine
Gingival margin Bonding composite resin to dentine is less reli-
able than bonding to enamel primarily due to dif-
ferences in composition and structure. The com-
Composite resin position of enamel and dentin44 is shown in Table
12.3. Dentine contains approximately twelve times
more water and twice the amount of organic mate-
rial than enamel. Water competes with bonding
Tooth structure agents for substrate surface and can also hydro-
lyse resin bonds.45 While enamel is relatively
homogeneous in structure, dentine is heteroge-
Fig. 12.3. Microleakage at the dentine margins of composite neous with the various constituents unevenly dis-
restorations arising from polymerisation shrinkage. tributed in peritubular and intertubular dentine.
 Composite Resins 207

Dentine bonding systems can be divided into three components can be mixed together to form
three groups based on the mechanism of adhe- ‘all-in-one self-conditioning adhesives’. The latter
sion.37 The first group aims to modify the smear systems usually employ weaker acids such as
layer and incorporate it into the bonding process. maleic, citric, oxalic or nitric acids as well as phos-
The smear layer has been defined as ‘any debris, phoric acid in lower concentrations.
calcific in nature, produced by reduction or An alternate method of effectively bonding com-
instrumentation of dentine, enamel or cemen- posite resin to tooth structure is to place a glass-
tum’.46 A second group dissolves the smear layer ionomer as a base, a lining or a bonding agent.
while the last group completely removes it. There is a variety of materials on the market and
The third group is the one that is commonly in the main advantage lies in the ion exchange adhe-
use now and the technique involves the use of sion of glass-ionomer to tooth structure that will
three components – acid etchant, primer and ensure the absence of microleakage. When used
adhesive. In the first generation of these systems as a base a high strength material is placed,
the components were applied in three consecutive trimmed to fit the cavity design, then etched to
steps. The technique is known as the ‘total etch allow a micromechanical union between the com-
technique’ and involves etching both enamel and posite resin and the glass-ionomer. On the other
dentine at the same time. The etchant removes hand there is a low powder, low viscosity, light
the smear layer and also demineralises the super- activated material available that can be placed as
ficial layer of dentin, leading to exposure of a a bonding agent on the floor and walls of the cav-
microporous scaffold of collagen fibrils. The sec- ity immediately prior to placement of the compos-
ond step involves the application of a primer that ite resin.48 Both materials can then be light acti-
contains hydrophilic monomers with an affinity vated at the same time. These techniques are dis-
for the exposed collagen fibrils. The primer also cussed in detail in Chapter 11.
contains hydrophobic monomers to copolymerise
with the adhesive which is an unfilled or lightly
filled resin. The monomers are usually dissolved NOTE "
in organic solvents, such as ethanol or acetone, • Composite resin bonding to dentine, though
which, due to their volatility, displace water from significantly improved, still remains a problem
the moist collagen network.47 The final step is to • Three-step smear removing (total-etch) systems
apply the adhesive and this engages the exposed are generally more effective than two and one-
step systems
collagen and forms resin tags deep in the dentinal
tubules and thereby generates a hybrid layer.
To simplify this time consuming three-step pro-
cedure, recent innovations have been directed
towards combining the various components into
two-step or one-step systems (Figure 12.4). Primers
have been combined with adhesives to form ‘one-
bottle’ systems. Etchants have been combined
with primers to form ‘self-etching primers’ and all

TABLE 12.3
Content Enamel Dentine

Inorganic 86% (hydroxyapatite) 50%

Organic 12% 25% (mainly type I collagen)

Water 2% 25%
Fig. 12.4. Smear removing bonding systems.
208 Preservation and Restoration of Tooth Structure

Clinical Considerations • contraindications include patients with

excessive wear and bruxism
Successful restorations in anterior teeth are
shown in Figures 12.5-11. Approved applications for
Indications and contraindications restoration of posterior teeth have been set out by

C omposite resins were first developed over 40

years ago and have shown considerable pro-
gress since. The following are the essential
the American Dental Association Council on
Scientific Affairs49 and include its use in small to
moderate sized occlusal proximal and cervical
requirements for successful placement: lesions.
• the best bond is obtained with enamel
around all the margins Selection criteria
• the cavity must be isolated from contamina- Placement of a composite resin restoration is a
tion so preferably use rubber dam highly technique sensitive procedure and is
• cavity must be accessible to the activator therefore heavily dependent on the knowledge
light for adequate polymerisation and skill of the operator. The whole process from
selection of the case, to the cavity preparation to
the final finishing demands an understanding of
the material and the rationale behind each step of
the placement technique.

Preoperative procedures
The tooth to be restored must be cleaned with a
paste of pumice and water only to remove plaque
and debris to ensure the correct shade is recorded.
Proprietary prophylaxis pastes often contain fluo-
ride and are best avoided as they may interfere
with bonding to enamel.

Selection of shade
Fig. 12.5a. Indication for the use of composite resin to The shade of a tooth is a highly complex issue of
restore a proximal lesion in an anterior tooth: Old the interplay of hue, chroma and value, including
composite resin restorations require replacement. metamerism, and the source of the light involved.

Fig. 12.5b. The old restorations have been removed with Fig. 12.5c. The completed restorations shortly after insertion.
minimal extension of the original cavity.
 Composite Resins 209

Fig. 12.6a. Indication for the use of composite resin to Fig. 12.6b. The completed restoration shortly after
restore a proximal lesion in an anterior tooth involving the replacement.
incisal angle: A prior restoration has fractured and requires Case by courtesy Dr. Betty Muk.
replacement.

Fig. 12.7a. Indications for the placement of composite Fig. 12.7b. The lesions have been restored using composite
resins to restore labial cervical lesions on anterior teeth: resin with a dentine bonding agent.
There are multiple shallow cervical noncarious lesions on these
anterior teeth requiring restoration with an aesthetic material.

Fig. 12.8a. Reshaping anterior teeth and closing diastema Fig. 12.8b. Careful addition of resin on the proximal surfaces
with composite resin: There is spacing between all anterior resulted in good size, proportion, physiological contours and
teeth for this patient who requests closure of the spaces. pleasing aesthetics.
210 Preservation and Restoration of Tooth Structure

Fig. 12.9a. Modification of anterior teeth using composite Fig. 12.9b. The size of the central incisor has been corrected,
resin: The maxillary right central incisor shows a size the canine has been reshaped to simulate a lateral incisor and
discrepancy in comparison with its matching neighbour. The the first bicuspids were veneered to mask discolouration.
lateral incisor is missing and the first premolars are discoloured.

Fig. 12.10a. The use of composite resin to disguise Fig. 12.10b. This subsequent photograph shows 20 direct resin
discoloured teeth: The patient was unhappy with the colour veneers, placed to modify the shade, 14 years after placement.
of the upper and lower anterior teeth. Bleaching was not There is only a small amount of labial abrasion.
available at that point in time.

Fig. 12.11a. The use of composite resin as an immediate Fig. 12.11b. The teeth have been restored with composite resin
repair following trauma: The patient was involved in an as an emergency procedure. The restorations will probably last
accident resulting in fracture of the maxillary central incisors. for some time.
 Composite Resins 211

Shade guides have serious limitations.50 The most will generally improve the proximal contour
reliable technique is to cure a small amount of and contact.
composite resin on to the actual tooth involved
before it has been allowed to dry out (Figure 12.12). Wedging
Many of the materials on the market encourage Wedging a matrix firmly in to place will achieve
the use of a layering technique to mimic the com- the following:
bination of enamel and dentine and/or body and • it will assist in maintaining a good contact,
incisal shades. particularly in posterior restorations
• it will protect the interproximal gingival tis-
Cavity preparation – guidelines sues
On the assumption that the disease of caries has • it will improve the shape, the proximal con-
been controlled first it is only necessary to remove tour and embrasure space
sufficient tooth structure to allow access to the The value of plastic transparent wedges to assist
area that is beyond remineralisation and healing in directing the activator light into interproximal
and therefore has to be replaced. There is no pre- regions has not been substantiated and clinically
scribed cavity form required. However, as the best it is much easier to work with a regular wooden
and strongest bond is that obtained between com- wedge.
posite resin and enamel, it is desirable to main-
tain an enamel margin around the full circumfer- Bonding procedures
ence of the lesion. The following basic require- As discussed above the development of a micro-
ments can be prescribed: mechanical adhesive union between enamel and
• internal cavity form should be rounded to composite resin is possible providing the proce-
avoid incorporation of stress points dures are carried out with due care.51 Bonding to
• bevel enamel margins to enhance the seal dentine is quite different and, in spite of much
between composite resin and enamel research, remains not entirely reliable. Alter-
• where aesthetics is important enlarge the natives have been suggested including the place-
bevel to provide a smooth transition of com- ment of a base of glass-ionomer to act as a dentine
posite resin to tooth structure substitute with composite resin laminated over it
• do not place a bevel on occlusal margins to to provide strength and aesthetics (Chapter 11).
avoid allowing thin sections of the restora-
tion to come under occlusal load
• do not place a bevel on the gingival margin
of a proximal box if it is in dentine
• access to a proximal lesion on an anterior
tooth should be from the lingual to preserve
the facial tooth structure and maintain aes-
thetics

Selection of matrix
The purpose of the matrix is to enhance adapta-
tion of the restoration to the gingival margin and
to provide some degree of contour to the proximal
surface.
• For an anterior tooth use a mylar or plastic
strip wedged firmly to place. Fig. 12.12. This is the recommended procedure for verification
of shade selection prior to commencement of restorative
• For a posterior tooth, use a precontoured
procedures. Place the trial piece of composite resin on the
transparent matrix for preference. labial of the tooth to be restored before it has become
• A sectional matrix with a ‘bitine’ or ‘G-ring’ dehydrated by further treatment.
212 Preservation and Restoration of Tooth Structure

Another alternative has been suggested with the may inadvertently be applied to the enamel, but
placement of a base of a flowable composite resin this will not affect the bond strength. The pre-
followed by a hybrid material over this to provide ferred adhesive is an unfilled or lightly filled resin
the required strength and wear resistance. It is of low viscosity that will penetrate deeply into the
suggested that the flowable material will allow for microporosities in the enamel resulting from the
improved adaptation to the cavity floor as well as etching process. This is a highly effective micro-
provide a degree of flexibility and a stress break- mechanical union and, on the assumption the
er effect.52 However, it will not bond with the den- enamel margin is strong, will provide excellent
tine any better than a hybrid composite resin and adhesion between composite resin and tooth
the glass-ionomer base remains the preferred structure.
option.
The total etch concept discussed above is proba- Bonding to dentine
bly the best resin to dentine bonding system cur- As discussed earlier, bonding to dentine is not as
rently available,53 particularly those systems that straightforward because the composition and
maintain the separate three-step procedure. structure of dentine is not homogeneous and it is
subject to change over time. Secondary, tertiary
Bonding to enamel and sclerotic dentine can be formed under various
The preferred acid is 37% orthophosphoric acid in circumstances and each will respond differently
a gel form and the application time is 15 seconds. to etching. Relative to enamel it is highly organic
The gel form is preferred because it allows for bet- and it is subject to constant hydrostatic pressure
ter control of placement, is easily seen and com- because of the positive dentine fluid flow. Over
plete removal can be easily monitored. Clinically, recent years several generations of bonding sys-
a well etched surface should exhibit a white, frost- tems have been developed in an attempt to cope
ed appearance indicating porosities to a depth of with the demanding requirements of a good den-
about 30 µm. This will now be a high energy sur- tine bond. The current systems are still depend-
face with a greatly increased surface area that is ent on a three-step approach although attempts
highly receptive to the uptake of the dentine have been made to modify this by combining
adhesive. steps together.
Etching is highly technique sensitive and suc- The steps required for effective etching, priming
cess depends upon the following: and bonding dentine are discussed above and the
• type and concentration of acid results are the same whether the steps are under-
• duration of etch taken separately or in combination. The primary
• complete rinsing away of the acid and etch- aim of demineralisation of the dentine is readily
ing debris achieved but keeping the collagen fibres standing
• surface must now remain free of contamina- discretely and ready to be invested with the bond
tion – preferrably under rubber dam is not easy. It is necessary to maintain some degree
• application of low viscosity adhesive will of hydration – but not too much – or the fibres will
allow optimum penetration just lie down and resist intake of bond. Having
• adhesive must be as thin as possible with no succeeded in developing a hybrid layer,54 it has to
pooling at the margins be recognised that the collagen fibres have been
Note that the type of enamel can vary so the devitalised through etching and, in time, may sep-
duration of etching will vary. The enamel of the arate out and release the bond. There is still the
primary dentition is relatively prismless and possibility of resin tags in the dentine tubules
enamel that has been subject to heavy applica- although this assumes that the tubules have been
tions of fluoride may require longer etch times to sufficiently dehydrated to allow penetration of the
achieve the desired white frosted appearance. resin at the time of bonding (Figure 10.8).
The placement of a primer is not required if all
margins are in enamel. When priming dentine, it
 Composite Resins 213

tion shrinkage and contraction stresses but stud-

NOTE " ies suggest that the degree of conversion may be
The bonding of reduced or, at best, remains unaffected.64,65
• enamel is micromechanical through acid etching However, it has also been suggested that polymers
and resin bonding cured this way demonstrate increased susceptibil-
• dentine is through hybridisation through acid ity to ethanol softening, reflecting a less cross-
etching, priming and adhesive linked structure in the final restoration.66
The pulse cure technique employs the use of
short pulses of light energy throughout place-
Placement of composite resin ment of the restoration but this technique has not
The effective placement of composite resin been widely investigated, compared to the pulse
depends on two factors: delay technique.
• control of polymerisation shrinkage
• full cure of the resin in depth
It is essential, therefore, that composite resins
NOTE "
are placed incrementally with no greater than • Stiffer composite materials may benefit more
from the use of controlled light polymerisation
2 mm thickness of resin in any one increment.
• The clinical durability of composites may be
Each layer must built one upon the other ensur-
compromised with the use of some controlled
ing that no voids are incorporated in between. light polymerisation techniques

Curing regimens
As mentioned earlier in this chapter, one of the Depth of cure
more recent approaches to reducing polymerisa- There are a variety of factors that will affect the
tion shrinkage stresses is the use of controlled depth of cure of an increment of composite resin.
light polymerisation. This can be achieved by It must be noted that, even when great care has
• soft start polymerisation been taken to ensure a full cure, no more that 70%
• pulse delay activation of the resin bonds will be fully polymerised. The
• pulse cure percentage may increase a little over time but the
• a combination of techniques important period to ensure an acceptable result is
Soft start or exponential/step polymerisation the time of placement. So far no curing light will
involves prepolymerisation at low light intensities penetrate further than 2 mm into a composite
followed by final cure at high intensity. This tech- resin so this automatically becomes the maxi-
nique has equivocal results with some studies mum thickness of an increment. The factors
finding no reduction in polymerisation shrink- affecting the depth of cure are as follows:
age,55,56 while others have reported a significant • thickness of the resin increment
reduction.57,58 The variations may be attributed to • duration of exposure to the light
differences in testing methodology, light energy • the particle size of the fillers
density and/or materials. Hybrid composites • percentage of filler by volume
appear to benefit most due to their high modulus • shade of the composite resin
of elasticity59 but the technique does not appear to • distance from light tip to resin
affect the mechanical properties or degree of con- • curing through tooth structure
version of composites.60 • diameter of light tip
Pulse delay activation involves an initial pre- • efficiency of the curing light
polymerisation at a low light intensity followed by
a delay period during which the composite Finishing the restoration
restoration is finished and polished. The restora- The proper selection and construction of the
tion is then finally cured at high intensity. This matrix followed by careful placement of the com-
technique has been shown to reduce polymerisa- posite resin increments will limit the amount of
214 Preservation and Restoration of Tooth Structure

finishing procedures required to complete a

restoration. Jefferies67 classified the instrumenta-
tion required into
• cutting instruments such as tungsten car-
bide burs
• abrasive instruments – including bonded,
coated and loose abrasives
• finishing and polishing devices
In addition, any small proximal or cervical
excess can be effectively removed with a #12
scalpel blade. (Figure 12.13) The occlusal contacts
are also checked at this final stage.
Fig. 12.13. This demonstrates the use of a #12 scalpel blade to
remove excess composite resin at the gingival margin
immediately upon completion of a restoration.
Longevity of posterior composite resin
restorations
There are many published reports on the clinical short term and it remains for the profession to
performance of composite resin restorations and continuously track their individual results and
recent reports suggest that the modern varieties assess the long term survival.
last well (Figures 12.14 and 12.15). However, it must
be noted that this is highly dependent on a num-
ber of factors including the size of the cavity, the
BE AWARE !
position of the tooth in the arch and the occlusal The clinical success of composite resin restorations is
load. The documented failure rate of 0-45 % for a highly dependent on the operator who must be
meticulous right from diagnosis to selection of the
series of studies from 1996-200368 demonstrates
material, placement technique and completion of the
clearly that the material needs to be placed selec- final restoration.
tively and fastidiously (Figure 12.16). It must be
noted that a large proportion of these studies are
 Composite Resins 215

Fig. 12.14a. Restoration of a small posterior lesion using Fig. 12.14b. The lesions have been located and limited
composite resin: Caries lesions have been identified extension cavities prepared ready for restoration.
interproximally at the mesial of the first molar and the distal of
the second bicuspid.

Fig. 12.14c. The completed restorations. Note the physiological Fig. 12.15a. Restoration of more extensive lesions with
contours and the aesthetic end result. composite resin: There are defective restorations in both the
Courtesy of Dr Pranee Wattanapayungkul. upper bicuspids that need to be replaced.

Fig. 12.15b. The old restorations have been removed revealing Fig. 12.15c. The second restoration has been removed showing
further caries. that there is further caries in the first bicuspid.
216 Preservation and Restoration of Tooth Structure

Fig. 12.15d. The completed restorations in both teeth. Note Fig. 12.16a. A series of composite restorations showing
the physiological contours. It could be suggested that the some common modes of failure (the reason for failure is not
translucency of the restorations could be improved. always obvious but poor clinical handling has to be a primary
Courtesy of Dr. Pranee Wattanapayungkul. reason): Worn and discoloured direct composite resin veneers.

Fig. 12.16b. Defective, leaking, discoloured, worn and partially Fig. 12.16c. There has been failure of the bond with this
dislodged composite resin restorations showing defective restoration leading to dislodgement of the restoration.
margins with recurrent caries.

Fig. 12.16d. A combination of wear, marginal leakage and a Fig. 12.16e. There is recurrent caries with staining and a
poor colour match indicates the need for replacement of the marginal fracture leading to a need for replacement of this
restoration. restoration.
 Composite Resins 217

Further Reading
1. Tyas MJ & Burrow MF. Clinical evaluation of a resin-modified 21. Shortall AC, Wilson HJ & Harrington E. Depth of cure of
glass-ionomer adhesive system: results at five years. Oper radiation-activated composite restoratives – influence of
Dent 2002; 27:438-441. shade and opacity. J Oral Rehabil 1995; 22:337-342.
2. McLean JW, Nicholson JW, Wilson AD. Proposed nomencla- 22. Yap AUJ. Effectiveness of polymerisation in composite
ture for glass-ionomer dental cements and related materials. restoratives claiming bulk placement: Impact of cavity depth
Quint Int 1994; 25:587-9. and exposure time. Oper Dent 2000; 25:113-120.
3. Yap AUJ, Mok YY Surface finish of a new hybrid aesthetic 23. Toledano M, Osorio R, Osorio E, Fuentes V, Prati C & Garcia-
restorative material. Oper Dent 2002; 27:161-6. Godoy F. Sorption and solubility of resin-based restorative
4. Yap AUJ, Tham SY, Zhu LY, Lee HK Short-term fluoride dental materials. J Dent 2003; 31:43-50.
release from various aesthetic restorative materials. Oper 24. Yap AUJ, Chew CL, Ong KL, Teoh SH. Environmental dam-
Dent 2002; 27:259-65. age and occlusal contact area wear of composite restorative.
5. Phillips RW. Past, present and future composite systems. J Oral Rehabil 2002; 29:87-97.
Dent Clinics NA 1981; 25:209-218. 25. Hofmann N, Renner J, Hugo B & Klaiber B. Elution of leach-
6. Ferracane JL. Current trends in dental composites. Crit Rev able components from resin composites after plasma arc ver-
Oral Biol Med 1995; 6:302-318. sus standard of soft-start halogen light irradiation. J Dent
7. Lutz F, Phillips RW, Roulet JF, Setcos JC. In vivo and in vitro 2003; 20:223-32.
wear of potential posterior composites. J Dent Res 1984; 63: 26. Ortengren U, Wellendorf H, Karlsson S & Ruyter IE. Water
914-920. sorption and solubility of dental composites and identifica-
8. Bayne SC, Heyman HO, Swift EJ. Update on dental compos- tion of monomers released in an aqueous environment.
ite restorations. JADA 1994; 125:687-701. J Oral Rehabil 2001; 28:1106-15.
9. Labella R, Lambrechts P, Van Meerbeek B, Vanherle G. 27. Lim BS, Moon HJ, Baek KW, Hahn SH, Kim CW. Color sta-
Polymerisation shrinkage and elasticity of flowable compos- bility of glass-ionomer cements and polyacid-modified resin-
ites and filled adhesives. Dent Mater 1999; 15:128-37. based composites in various environmental solutions. Am J
10. Bayne SC, Thompson J, Swift E, Stamatiades P, Wilkerson M. Dent 2001; 14:241-6.
A characterization of first-generation flowable composites. 28. Lee YK, Zawahry M, Noaman KM & Powers JM. Effect of
JADA 1998; 129:567-577. mouthwash and accelerated aging on the color stability of
11. Jain P& Belcher M. Microleakage of Class II resin-based esthetic restorative materials. Am J Dent 2000; 13:159-61.
composite restorations with flowable composite in the prox- 29. Schulze KA, Marshall SJ, Gansky SA & Marshall GW. Color
imal box. Am J Dent 2000; 13:235-8. stability and hardness in dental composites after accelerated
12. Braga R, Hilton T, Ferracane J. Contraction stress of flowable aging. Dent Mater 2003; 19:612-9.
composite materials and their efficacy as stress-relieving lay- 30. Folwaczny M, Loher C, Mehl A, Kunzelmann KH, Hickel R
ers. JADA 2003; 134 :721-28. (2000) Tooth-colored filling materials for the restoration of
13. Leinfelder K, Bayne S and Swift E. Packable Composites: cervical lesions: a 24-month follow-up. Oper Dent 2000;
overview and technical considerations. J Esthet Dent 1999; 25:251-8.
11:234-249. 31. Iazzetti G, Burgess JO, Gardiner D, Ripps A. Color stability of
14. Rueggeberg FA, Caughman WF & Curtis JW. Effect of light fluoride containing restorative materials. Oper Dent 2000;
intensity and exposure duration on cure of resin composite. 26: 520-5.
Oper Dent 1994;19:26-32. 32. Uchida H, Vaidyanathan J, Viswanadhan T, Vaidyanathan
15. Jain P & Pershing A. Depth of cure and microleakage with TK. Colour stability of dental composites as a function of
high-intensity and ramped resin-based composite curing shade. J Prosthet Dent 1998; 79:372-377.
lights. J Am Dent Assoc 2003; 134:1215-23. 33. Yap AUJ, Sim CPC, Loganathan V. Polymerisation color
16. Yap AU, Wang HB, Siow KS, Gan LM. Polymerisation shrink- changes of esthetic restoratives. Oper Dent 1999; 24:306-
age of visible light cured composites. Oper Dent 2000; 23: 311.
98-103. 34. McGuckin RS, Tao L, Thompson WO, Pashley DH. Shear
17. Ølio G. Biodegradation of dental composites/glass ionomer bond strength of Scotchbond 2 in vivo. Dent Mater 1991; 7:
cements. Adv Dent Res 1992; 6:50-54. 50-53.
18. Yap AUJ, Saw TY, Cao T, Ng MM. Composite cure and pulp- 35. Mair LH, Stolarski TA, Volwles RW, Lloyds CH. Wear: mech-
cell cytotoxicity associated with LED curing lights. Oper Dent anisms, manifestations and measurement. J Dent 1996; 24:
2004; 29: 92-99. 141-148.
19. Pilo R & Cardash HS. Post-irradiation polymerisation of dif- 36. Leinfelder KF, Taylor DF, Barkmeier WW, Goldberg AJ.
ferent anterior and posterior visible light-activated resin Quantitative wear measurement of posterior resins. Dent
composites. Dent Mater 1992; 8:299-304. Mater 1986; 2:198-201.
20. Ferracane JL. Dental composites: Present status and research 37. Lundin SA, Andersson B, Koch G & Rasmusson G. Class II
directions. Second International Congress on Dental Materi- composite resin restorations: A three-year clinical study of
als 1993; 45-53. six different posterior composites. Swed Dent J 1990; 14:
105-114.
218 Preservation and Restoration of Tooth Structure

38. Lambrechts P, Braem M & Vanherle G. Evaluation of clinical 54. Nakabayashi N, Kojima K, Masuhara E. The promotion of
performance of posterior composite resin and dentin adhe- adhesion by the infiltration of monomers into tooth sub-
sives. Oper Dent 1987; 12:53-78. strates. J Biomed Mater Res 1982; 16:26-273.
39. Yap AUJ, Tan CH, Chung SM. Wear behaviour of new com- 55. Rahiotis C, Kakaboura A, Loukidis M, Vougiouklakis G.
posite restoratives. Oper Dent 2004; 29:277-282. Curing efficiency of various types of light-curing units. Eur J
40. Davidson CL & Feilzer AJ. Polymerisation shrinkage and Oral Sci 2004;112:89-94.
polymerisation shrinkage stress in polymer-based restora- 56. Yap AU, Soh MS, Siow KS. Post-gel shrinkage with pulse acti-
tions. J Dent 1997; 25:435-440. vation and soft-start polymerisation. Oper Dent 2002; 27:
41. Davidson CL & De Gee AJ. Relaxation of polymerisation 81-87.
contraction stresses by flow in dental composites. J Dent Res 57. Hofmann N, Markert T, Hugo B, Klaiber B. Effect of high
1984; 63:146-148. intensity vs. soft-start halogen irradiation on light-cured
42. Feilzer AJ, de Gee AJ & Davidson CL. Setting stress in com- resin-based composites. Part 1. Temperature rise and poly-
posite resin in relation to configuration of the restoration. merisation shrinkage. Am J Dent 2003; 16:421-430.
J Dent Res 1987; 68:1636-1639. 58. Lim BS, Ferracane JL, Sakaguchi RL, Condon RL. Reduction
43. Van Meerbeek B, Inoue S, Perdiago J, Lambrechts P & of polymerisation contraction stress for dental composites by
Vanherle G. Enamel and dentin adhesion. In Fundamentals two-step light-activation. Dent Mater 2002; 18:436-444.
of Operative Dentistry, 2nd ed. Quintessence Publishing; 59. Rueggeberg FA, Caughman WF, Curtis JW Jr. Effect of light
2001; 236-259. intensity and exposure duration on cure of resin composite.
44. Van Meerbeek B, Perdigao J, Lambrechts P & Vanherle G. Oper Dent 1994; 19:26-32.
The clinical performance of adhesives. J Dent 1998; 26:1- 60. Bouschlicher MR, Rueggeberg FA. Effect of ramped light
20. intensity on polymerisation force and conversion in a pho-
45. McLean JW. Dentinal bonding agents versus glass ionomer toactivated composite. J Esthet Dent 2000; 12:328-339.
cements. Quint Int 1996; 27:659-667. 61. Chye CH, Yap AU, Lai YC, Soh MS. Post-gel shrinkage asso-
46. Ishioka S & Caputo AA. Interaction between the dentinal ciated with different light curing regimens. Oper Dent
smear layer and composite bond strengths. J Prosthet Dent. (accepted for publication).
1989; 61:180-185. 62. Sahafi A, Peutzfeldt A, Asmussen E. Effect of pulse-delay cur-
47. Jacobsen T, Ma R, Soderholm KJ. Dentin bonding through ing on in vitro wall-to-wall contraction of composite in
interpenetrating network formation. Transactions of the dentin cavity preparations. Am J Dent 2001; 14:295-296.
Academy of Dental Materials 1994; 7:45-52. 63. Suh BI, Feng L, Wang Y, Cripe C, Cincione F, de Rijik W. The
48. Peumans M, Van Meerbeek B, Lambrechts P & Vanherle G. effect of the pulse-delay technique on residual strain in com-
Two-year clinical effectiveness of a resin-modified glass posites. Compend Contin Educ Dent 1999; 20(S):4-12.
ionomer adhesive. Am J Dent 2003; 16:363-368. 64. Hackman ST, Pohjola RM, Rueggeberg FA. Depths of cure
49. ADA Council on Scientific Affairs: ADA Council on Dental and effect of shade using pulse-delay and continuous expo-
Benefit programs, Statement on posterior resin-based com- sure photo-curing technique. Oper Dent 2002; 27:593-599.
posites. JADA 1998; 129:1627-8. 65. Asmussen E, Peutzfeldt A. Influence of pulse-delay curing on
50. Yap AUJ, S Bhole and KBC Tan. Shade match of tooth- softening of polymer structures. J Dent Res 2001; 80:1570-
coloured restorative material based on a commercial shade 1573.
guide. Quint Int 1995; 26:697-702. 66. Soh MS, Yap AU. Influence of curing modes on crosslink
51. Yap AUJ, Ho KS & Wong KM. Comparison of marginal seal- density in polymer structures. J Dent 2004; 32:321-326.
ing ability of new generation bonding systems. J Oral 67. Jefferies SR. The art and science of abrasive finishing and
Rehabil. 1998; 25:666-671. polishing in restorative dentistry. DCNA 1998; 42:613-627.
52. Bayne SC, Thompson JY, Swift EJ et.al. A characterization of 68. Brunthaler A, Konig F, Lucas T et al. Longevity of direct resin
first-generation flowable composites. JADA 1998; 129:567- composite restorations in posterior teeth. Clin Oral Investig
577. 2003; 7:63-70.
53. Kanca J. Bonding to tooth structure: A rational rationale for
a clinical protocol. J Esthet Dent 1989; 1:135-138.